Current Understanding of the Pathophysiology and Novel Treatments of Interstitial Cystitis/Bladder Pain Syndrome

Abstract

The pathophysiology of interstitial cystitis/bladder pain syndrome (IC/BPS) is multifactorial. Identifying the clinical characteristics and cystoscopic findings of bladder-centered IC/BPS facilitates optimal treatment strategies targeting the diseased urinary bladder. Patients with Hunner’s lesion (HIC) and without Hunner’s lesion (NHIC) should be treated differently. Based on the histopathological findings, NHIC can be treated with intravesical instillation of urothelial protective agents, such as hyaluronic acid, to cover the urothelial defects. In non-responders, chronic inflammation and higher urothelial dysfunction can be treated with intravesical botulinum toxin A injection, platelet-rich plasma injection, or low-energy shock wave treatment to reduce inflammation, increase tissue regeneration, and improve the urothelial barrier. Patients with HIC should be treated with electrocauterization first; augmentation enterocystoplasty should only be used in end-stage HIC when the contracted bladder is refractory to other treatments. The antiviral agent, valacyclovir, can be used in patients with HIC, small bladder capacity, and high-grade glomerulations. In addition, behavioral modification is always recommended from the beginning of treatment. Treatment with cognitive behavioral therapy interventions in combination with bladder therapy can reduce anxiety and improve treatment outcomes. Herein, recent advances in the pathophysiology and novel treatments for IC/BPS are reviewed.

Multimodal Treatment with Cognitive Behavioral Therapeutic Intervention Plus Bladder Treatment Is More Effective than Monotherapy for Patients with Interstitial Cystitis/Bladder Pain Syndrome—A Randomized Clinical Trial

“…The maximal bladder capacity (MBC), glomerulation grade after cystoscopic hydrodistention, and uroflowmetry parameters were recorded. After cystoscopic hydrodistention, patients were consecutively treated with bladder-targeting medications for bladder pain, including nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 inhibitors, antimuscarinics, alpha-blockers, intravesical hyaluronic acid (HA) instillations, and intravesical botulinum toxin A (BoNT-A) injections [ 2 ] or novel treatment with plasma-rich platelet (PRP) injection [ 8 ].…”

“…The former category includes cystoscopic hydrodistention, oral analgesic and anti-inflammatory drugs, intravesical hyaluronic or chondrointin instillation, and intravesical Botox injections [ 1 , 2 ]. Experimental therapies include sacral nerve stimulation, intravesical steroid injection, low-energy shock-wave therapy, and intravesical platelet-rich plasma injection [ 7 , 8 ]. For IC patients with Hunner’s lesion, transurethral resection of the ulcer, and partial cystectomy with or without bladder augmentation might be necessary to eradicate the severe bladder pain and contracted bladder [ 1 , 2 ].…”

Treatment Outcomes of Intravesical Botulinum Toxin A Injections on Patients with Interstitial Cystitis/Bladder Pain Syndrome

“…In other words, there are approximately 100,000 people with IC/BPS in Taiwan. The pathophysiology is still unclear, and patients with this condition have not achieved satisfactory treatment outcomes [2]. IC/BPS can be classified into Hunner's (HIC) or non-Hunner's (NHIC) ulcer types [1].…”

“…IC/BPS can be classified into Hunner's (HIC) or non-Hunner's (NHIC) ulcer types [1]. The most common pathological findings are urothelial denudation and bladder inflammation [2]. Failure to achieve full urothelial regeneration results in potential breaches in barrier function that may increase an individual's susceptibility to infection or increase sensory fiber stimulation [3].…”

“…Instead, multiple and simultaneous treatments were suggested [1,[4][5][6]. Overall, the treatments include pain control, lifestyle modification, stress management, pelvic floor muscle therapy, oral therapies, intravesical therapies, and novel treatment for bladder inflammation [2].…”